Application of Lean Thinking to Health Care: Issues and Observations

Tom Joosten; Inge Bongers; Richard Janssen


Int J Qual Health Care. 2009;21(5):341-347. 

In This Article

Abstract and Background


Background. Incidents and quality problems are a prime cause why health care leaders are calling to redesign health care delivery. One of the concepts used is lean thinking. Yet, lean often leads to resistance. Also, there is a lack of high quality evidence supporting lean premises. In this paper, we present an overview of lean thinking and its application to health care.
Development, theory and application of lean thinking to health care. Lean thinking evolved from a tool designed to improve operational shop-floor performance at an automotive manufacturer to a management approach with both operational and sociotechnical aspects. Sociotechnical dynamics have until recently not received much attention. At the same time a balanced approach might lead to a situation where operational and sociotechnial improvements are mutually reinforcing. Application to health care has been limited and focussed mainly on operational aspects using original lean tools. A more integrative approach would be to pay more attention to sociotechnical dynamics of lean implementation efforts. Also, the need to use the original lean tools may be limited, because health care may have different instruments and tools already in use that are in line with lean thinking principles.
Discussion. We believe lean thinking has the potential to improve health care delivery. At the same time, there are methodological and practical considerations that need to be taken into account. Otherwise, lean implementation will be superficial and fail, adding to existing resistance and making it more difficult to improve health care in the long term.


In 2008, the death of a 47-year-old patient in a Dutch Mental Health care Institute led to a firestorm of protest. The subsequent investigation uncovered serious organizational and clinical quality problems, despite the Institute having a certified quality management system. Incidents and problems like this are a prime reason that policy makers and health care leaders are calling to redesign care.[1]

One of the more popular concepts currently is lean thinking. On first sight, lean thinking seems an approach that generates positive results.[2,3] But its application also leads to resistance. The argument is that business approaches like lean thinking neglect the sociotechnical aspects that are unique to health care.[4] In mental health care for example, some signal a risk of 'interference with the delicate therapeutic process and increased work stress and burn-out for professionals'.[5]

A closer look at the results of lean thinking and other redesign studies also reveals other problems. Some commentators suggest that publication bias tends to highlight favourable results.[6] Despite this, a recent review identified only a few studies with a controlled before–after study design. To make matters worse, a wide range of often non-comparable measures was used, while some of the reported results were not even mentioned in the objective of the study and vice versa.[7]

While some believe that lean thinking can contribute to health care improvement, much work has to be done to substantiate this claim. The purpose of this perspective on quality article is to describe an understanding of lean thinking and its application in health care.


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